All information is required in order for your provider to release your records to our office.Instructions - Provide the following information:
- Patient Name and Date of Birth
- The name, address, phone# and/or fax# of the Provider who holds your records.
- Check the box of each record that you want released. Provide the date or date range for each item checked.
- Sign and date at the bottom. If you are not the patient, provide your relationship.

You have two options to submit your request:
1. Return the completed form to us. We will submit the form to the Provider that holds your records.
2. Give the completed form directly to the Provider that holds your records. We have provided our phone, fax and mailing address on the form so they can send your records to us.